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Health

Polycystic Ovary Syndrome

By Julie Stelting RN CDE

Girls as young as 12 years old have been diagnosed with polycystic ovarian syndrome (PCOS). But what is the connection between PCOS and insulin resistance?

Many teenage girls are placed on birth control pills to regulate their cycles, improve pain associated with their periods and improve acne. These are all signs of PCOS. Although birth control pills improve the symptoms, they mask this potential problem which can create fertility problems in their future. (Gambineri, 2012) Irregular cycles, period pain, and acne are all signs of PCOS. When diagnosed early, PCOS can be cured and future infertility problems can be avoided. PCOS is increased with abdominal fat. To prevent PCOS, we must consider how abdominal fat effects body chemistry.

What is the PCOS and Insulin Resistance Connection?

The exact cause of PCOS is unknown. PCOS is involved with the endocrine system which is a feedback hormone system that involves the whole body. Since this is involved with the hormones, it is understandable that young girls going through puberty are at higher risk. These hormone changes during puberty also encourages weight gain. Biologically, their body is preparing for a pregnancy. Unfortunately, young girls who are not thin are at risk for gaining too much weight which can result in insulin resistance and contribute to PCOS.

As body mass index (BMI) increases, the incidence of PCOS also increases. Up to 70% of women with PCOS are classified as obese. (Barber & Franks, 2012) When diagnosed early, PCOS frequently resolves with substantial weight loss. (Barber & Franks, 2012) Many people who are trying to lose weight benefit from a support group or an individual coach.

How do you test for PCOS?

Sex Hormone Binding Globulin (SHBG) is a common blood test used to predict PCOS. Increased body fat and insulin resistance decreases the liver’s production of SHBG. (Sex Hormone Binding Globulin and PCOS, n.d.) In fact, the decreasing SHBG levels are being used to identify insulin resistance and prediabetes before the pancreatic beta cells die off and blood sugar levels rise. (Gambineri, 2012) Diabetes can be prevented with early detection before the beta cells die.

Fifty percent of women with PCOS will develop prediabetes or Type 2 diabetes before the age of 40. ((APS), 2015) Increasing weight is associated with insulin resistance and hyperinsulinemia (increased levels of insulin in the blood). (Barber & Franks, 2012) Before blood sugar levels are uncontrollable, the pancreas goes into high production. When the problems associated with insulin resistance are not resolved, the beta cells will die off. This triggers uncontrolled blood sugar which is diagnosed as prediabetes or type 2 diabetes.

How is PCOS and Insulin Resistance related to Fertility Issues?

Insulin resistance in PCOS is well recognized. Up to 90% of women with PCOS are insulin resistant. (Spero, 2016) The presences of high levels of insulin inhibits ovarian folliculogenesis (the development of the follicles). (Willis, Watson, Mason, Brincat, & Franks, 1998) Think of this like fruit with its seeds inside. When the outside of the fruit (follicles) don’t ripen, the seed (or eggs) inside are not released and it forms a cyst. This is easy to see on diagnostic pictures.

Increased levels of insulin not only inhibit folliculogenesis but also stimulates the production of testosterone which suppresses the ovaries. (Spero, 2016) High levels of testosterone is associated with acne. One of the benefits of taking birth control pills is improved acne. Acne can also be caused by bacteria, so it is important to be properly evaluated for this problem.

How is PCOS treated?

Metformin is the first prescription used for PCOS. It is also the first medication used in diabetes management. (Gambineri, 2012) It works to improve the liver functions. The liver synthesizes SHBG as well as helps to regulate blood glucose. (Gambineri, 2012) Real improvements in liver function will result in improved PCOS and blood sugar control. Unfortunately, Metformin has a side effect of GI upset. If it is started at a low (tolerable) dose and increased as tolerated, most of the side effects can be avoided. Many clinicians are starting Metformin at a lower dose than is recommended to improve patient compliance. Metformin also has a time released formula available. Clients need to be encouraged to take this Rx.

Can PCOS be prevented?

There is no known prevention for PCOS. (Clinic, 2017)

Improved lifestyle habits are key to improving PCOS. (Spero, 2016)

Lifestyle changes include:

Reduce refined carbohydrates

Increase dietary fiber

Regular exercise

Eating for your body’s limitations with small frequent meals

Reduce processed foods

Eliminate alcohol, smoking and caffeine

Be evaluated for individual needs of supplemental vitamin D and chromium

It is far better to understand the causes of your teen’s problems than it is to simply mask the symptoms. Placing teens on birth control pills to control the symptoms can cause significant fertility problems in their future by masking the signs of PCOS.

Back to School with Type 2 Diabetes

Each new school year brings new challenges, particularly with diabetic students. Back to School Preparations are different when your child has diabetes. A parent’s ultimate responsibility is to teach their children to be independent, no matter what the situation. My experience with parents of school age children with diabetes varies widely.

Many times, school officials do not know if diabetic students are type 1 or type 2. Although the difference between the two conditions is like night and day, students are treated much the same way. It is unfortunate at this time in the USA, that approved medications for Type 2 in children are limited to Metformin and insulin. Insulin is a serious medication with significant side effects if not administered properly. I understand why parents are fearful for unfamiliar staff to give insulin to their child. For this reason, parents need to teach their child about insulin dosing so that the child will be self-assured and assertive to ask questions of adults when needed.

Kids can learn amazing things. While I was medical staff at a Type 1 diabetes camp, I had some amazing experiences. I worked with the youngest group ages 6-8 years old. Danny (fictitious name), was diagnosed at age 2 years and had an older sister who was also Type 1. Although he was 7 years old, he could already feel his blood sugars dropping when he was outside playing and he knew how to appropriately treat his low. He could “guestimate” what he was eating at each meal and calculate his insulin correctly. He had to be supervised, but at a very young age he had learned how to live with his “organ failure” and still be as normal as possible. Kids can learn with parental support.

Diabetes Priorities Vary with Age

According to the American Association of Diabetes Educators (AADE) diabetes priorities vary with age. (BC-ADM, 2014)

*Preschool and early elementary school students (ages 3-7 years) need to develop self-confidence. They need to learn to trust school staff to take care of their unique needs. Parents have the responsibility to educate other caregivers about their child’s specific needs. Many times blood glucose readings are seen as “good” or “bad”. Children have a strong desire to please parents. Fear of failure can cause children to falsify their numbers. Parents need to teach their children that blood glucose readings are just used to monitor their medication needs and never meant to evaluate their child’s behavior. Developing trust with your child is very important in this phase. (BC-ADM, 2014)

*Older elementary school ages 8-11 years need to develop self-esteem with respect to friends and peer groups. Diabetes management needs to center around a flexible regiment to allow participation in many activities. Their education needs to include how to avoid and treat hypoglycemic events. Parents need to observe blood glucose testing. Parents also need to progress in teaching their children about insulin dosing and self-administration. It is also important to teach their children how to participate in special occasions (example: birthday parties particularly at school). (BC-ADM, 2014)

*Early adolescents (ages 12-15 years old) can be very challenging. Normal hormone changes during puberty will cause blood sugars to be unpredictable. Parents need to be cautious about blaming their child of eating extra foods. Although they may be very hungry due to growth hormone, other hormone shifts will cause major troubles with blood sugars. It is important for parents and children to communicate honestly to avoid emotional problems. Diabetes priorities in addition to blood glucose control include monitoring for body image distortion, eating disorders, risky behaviors and depression. Although students may learn maintaining high blood sugars can create weigh lose, they also need to be taught the dangers of complications from uncontrolled diabetes like blindness, strokes and heart disease.

Family conflicts need to be intervened possibly with a professional family counseling. Turmoil between parent and child is very common at this phase. Children want more independence while parents are very fearful of the results. There is a high divorce rate in families with diabetic kids. Counseling may be beneficial for the whole family. (BC-ADM, 2014)

*Young adults (ages 16-19) Diabetes priorities include integrating diabetes into their lifestyle after high school. Young adults need to learn good coping skills for self-management. Teen and parent conflicts are common even without diabetes. There is a normal separation of the child from the family unit. Teens begin planning for their future independence. It is the parent’s responsibility to transition their teen into independent living. This includes developmentally challenged young adults. (BC-ADM, 2014)

When appropriate, it is very important for parents to educate their child about the effects of alcohol on blood sugars. I have seen so many diabetic college students in the emergency room. If you don’t know the dangers of alcohol abuse with diabetes, I encourage you to educate yourself and your child. For more information, see my blog post on alcohol and blood sugars.

Focus Forward on your future versus living by default.

The world can be a very scary place. I have a fear of heights. If I were walking on that bridge I would be frozen if I started looking around. Focus forward and be determined to put one foot in front of the other. Your health is like that too.

Most of us live by default, taking care of the business at hand, instead of planning for your future. But when it comes to your health, prevention is the best medicine.

We all do preventative health, like taking vitamins or brushing your teeth or vaccinating our kids. We know the value of prevention. But it is easier to live by default. For example, not making a plan to include exercise in your daily routine is so much easier than failing to do your exercises.

None of us want to face failure! When you make plans you run the risk of failing to complete it. So we just don’t plan for our future. I call this living by default.

We get busy! Or we fill our days with things to do. But what if you set a priority on your future health? How would that change what you do every day?

Sometimes we need a motivation and sometimes our body gives us a hint like high blood pressure. Your doctor puts you on a prescription for blood pressure and you start to think about what you are doing that contributes to it. Doctor says cut down on fatty foods and avoid salt and of course lose weight. We might watch our diet, we might try to avoid adding salt. What if your doctor said, “High blood pressure is the first sign of heart failure.” Would you take it more seriously? Would you start to look at your genetics to identify who died of heart disease? What did they do wrong?

Many chronic conditions are a result of things we do in our everyday lives that contribute to our future health over years. For example: take weight gain. Most of us gain a little more weight each year of our lives. When you live by default, you have the attitude of ‘I’ll get around to it later.’ When you focus on your future health, you don’t let it build up. You see what is happening and take action.

Sometimes you are motivated by your own body. Personally, I have arthritis in my knees and when I gain weight, my knees hurt and I start doing less due to chronic pain. I don’t want to live that way. I make a conscious choice to change it. But many people need a support buddy.

A support buddy is key to avoid living by default. You can do this through a social media group or individual counseling. My point, “Focus Forward!” on your future for your family. Your family needs you at your best!

Genetics is not everything. You can overcome your genetics through healthy living. Make the decision to make your life a high priority.

Syndrome X, aka Metabolic Syndrome or Obesity Syndrome

Syndrome X is a diagnosis you might here if you are at risk for a chronic disease, which is also known as Metabolic Syndrome. This is a group of health conditions that puts an individual at risk for chronic health problems like heart disease, strokes, and diabetes, plus high blood pressure and obesity.

Metabolic syndrome includes: (you must have at least 3 risk factors for this diagnosis)

Another common problem in metabolic syndrome is unacceptable levels of triglycerides. Many times triglycerides go up when people eat more calories during the day than they are burning. If you have above range triglycerides or are taking medications to control your triglycerides, then you are at risk for chronic disease.

If your LDL (low-density cholesterol) levels are high, that is another risk factor for a Syndrome X diagnosis. Cholesterol is often a reflection of the food you eat. Typically this is a high fat diet. It amazes me how many adolescents today are on cholesterol lowering medications. If you don’t know your cholesterol numbers, then you need to consult your medical provider and seek a blood test. Total blood cholesterol should be less than 200. If you are taking a medication to lower your cholesterol, then technically you have this medical diagnosis.

Metabolic syndrome includes blood pressure higher than preferred. I will say, trying to get accurate blood pressure reading on teens is difficult at best. First, acceptable pediatric blood pressures are difficult to pin down. You need to be educated in pediatric medicine to know what is acceptable. (Don’t go to the drug store with your children and get a reading; adult blood pressures are different from children’s numbers. Even adult sized machines can give wrong information for children.) Teens blood pressure can swing with changing thoughts (ask them about their personal problems and it will jump quickly).

My point: if a teen is taking medication for blood pressure, then they have been diagnosed with a health problem. At that time, the blood pressure may be within normal ranges, but they still have the diagnoses. This places them at higher risk for chronic disease like heart disease and kidney disease.

Metabolic Syndrome Risk Factors include:

insulin resistance

stress

diet (sugar-sweetened drinks)

genetics & age

low physical activity

disrupted sleep patterns

mood disorders

excess alcohol

smoking (tobacco and other substances)

chronic inflammation

other chemical imbalances in the blood.

Metabolic Syndrome Associated Health Conditions include:

Polycystic ovary disease

Erectile dysfunction

Hyperuricemia (uric acid in the blood)

Acanthosis nigricans

Fatty liver & Non-alcoholic fatty live disease

(More later on teens with fatty liver disease. I have been absolutely amazed at the number of preteens that I have seen diagnosed with fatty liver disease!)

Children at Risk for Chronic Disease Due to Obesity

In previous generations, the medical profession had few occasions to monitor children for adult health issues. Today, children are experiencing increasing problems with high blood pressure, high cholesterol and other health problems related to obesity. Although obesity is ever increasing in children, many times our health care system is lagging behind in identification and approved treatment.

Obesity is the main cause for kids being at risk for Type 2 diabetes and heart disease. Children are classified as overweight who are above the 85th percentile for age and sex. To be classified as obese, a child’s BMI will be over the 95th percentile for age and sex or their weight is greater than 120% over ideal for height(1). But being at risk for diabetes is much more than just a weight issue.

First: If one or both parents have been diagnosed with diabetes, then the child has the genetics putting them at risk for diabetes.

According to the SEARCH study, at least 75% of youth diagnosed with type 2 have at least one close family member who has diabetes. (Close family members include mother father sisters or brothers.) (searchfordiabetes.org)

Second: If the child’s BMI (body mass index) is over 28, it indicates that their life-style places them at additional risk.

Third: If they have high blood pressure. This one is tricky because blood pressure can be affected by many things including anxiety. If you or your child become anxious about going to the doctor, then chances are your blood pressure will be elevated. Taking several deep breaths before taking the blood pressure can help. It is important to get an accurate reading.

If you would like to monitor a child’s blood pressure, there are automatic machines available at most pharmacies and many department stores. I recommend using one of these machines because they are more reliable (ensure accurate readings) as compared to home monitors. Doctors are wanting blood pressure reading less than the 90th percentile on at least three measurements.(2) You can refer to the CDC guidelines for these recommended values.

The rule of thumb for children age 7-15 years old is: multiple 2 times your child’s age and add 90. This gives you the median for systolic pressure (the upper number). For the diastolic (lower number) subtract 30-45 from your systolic number. This is just an average number, the number you get can be higher or lower (for more information see: http://www.fpnotebook.com/CV/Exam/PdtrcVtlSgns.htm)

Fourth: Dyslipidemia. Now that is a big word! It means high cholesterol or high triglycerides. You need a fasting blood test to check for these conditions. Ask your doctor for this information.

Fifth: High Blood Sugar. Teens with a fasting blood glucose (FBG) 100 – 125 mg/dL or a random blood test greater than 199 mg/dL are at risk. For children younger than their teens, you should consult your pediatrician for this information. A1C is a non-fasting blood test. The results will vary with the age of your child.

A1C is not recommended to use to diagnose diabetes in children so it may not be covered by insurance. It is a good indicator if your teen’s tolerance to sugar is a problem. Younger children run higher blood sugars and the A1C test is not recommended for them. The readings for A1C are determined by the age of the child and industry standards have NOT be determined (as of this writing).

American Diabetes Association recommends testing asymptomatic youth for Type 2 if they are overweight plus any 2 of the following risk factors:

Mother with a history of gestational diabetes during the child’s gestation

Signs of insulin resistance or conditions associated with insulin resistance including acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome or small for gestational age birth weight(3)

Symptoms of high blood sugar include:

Unusual Thirst (they can’t drink enough)

Frequent urination (going to the bathroom more than once in the night)

Headaches, especially after eating sugary foods

Tired, no energy; especially after a meal

Unusually hungry; (I have seen these kids start eating two full lunches – this indicates a hormone imbalance)

2) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128 (suppl 5):S213-S256.

Stages of Motivation

There are stages you go through with any change in your life. This refers to the stages of motivation. Pre-contemplation, contemplation, preparation, action, maintenance, and then falling off the wagon. Think of how many times you have started a diet, maybe been successful losing weight, and then falling back into old habits.

Stages of Motivation for Changes

There are many stages of motivation for lifestyle changes. Many times we do really well, and we backslide. Then we may find the motivation to improve our lives again. And probably backslide again. We can’t teach children the same way we teach adults. I believe if we can teach them healthy lifestyles as children, it will carry over into adulthood.

But what motivates you to make changes? That is a hard question that only you can answer. A good coach can give suggestions but only you know what works for you. Communication is key. You have to work with someone you trust and be willing to communicate with them.

The first stage is education

The first stage is to be educated enough to know what to do. Most diabetes educators try to educate you on the problems high blood sugars cause in your body. They may focus on the complications high blood sugars can cause, like heart attacks and blindness and lower limb amputations. But many people get overwhelmed with everything involved with diabetes management and just give up. We can never give up on our kids!

I ask you – what will it take for you to seriously make life changes?

A motivation that says: I don’t care what it takes, I won’t put up with this anymore.

I will take charge of life…. quit living a life of default, and do what is best for my family!

Just be aware, if you are diagnosed with prediabetes, 99% of you will become diabetic if no changes in your lifestyle are made. I have seen so many diabetics take it seriously after the damage of high blood sugar is done. Diabetes Prevention Research show 58% of people who take charge of their lives when diagnosed with prediabetes can prevent this progression. It can be done. Seventy percent of people over 60 years old have successfully prevented or delayed this progression through lifestyle changes. (Could they be more motivated by their age?)